Improving Sexual & Urological Health in Males and Females | Dr. Rena Malik

KEYPOINTS

• 01

  Many people need to relax their pelvic floor, not strengthen it

  Malik, a urologist, explains that the pelvic floor muscles control both urination and sexual function. A common problem, especially in people who sit for long periods, is a pelvic floor that's too tight and short rather than too weak, and it can cause pain, urinary symptoms and sexual dysfunction. Huberman's own experiment with Kegels quickly left him with painful urination.

• 02

  Kegels help some people and harm others

  A Kegel means squeezing the muscles you'd use to stop your urine flow (not while actually urinating) and then fully relaxing. For men, the cue is lifting the penis without touching it. Kegels are mainly prescribed for stress urinary incontinence, leakage when coughing, sneezing, lifting or jumping. Doing too many creates a tense pelvic floor. Malik recommends a pelvic floor physical therapist to check your technique.

• 03

  Hormones cause only a small share of sexual dysfunction

  Only about 3–6% of erectile dysfunction is hormonal. Most problems involve blood flow, nerves, the pelvic floor or psychology. Desire (the mental wanting) is distinct from arousal (erection or lubrication). Huberman notes that estrogen supports libido in both sexes: men who crush their estrogen with drugs like anastrozole often lose their libido.

• 04

  Erectile problems in young men often come from the pelvic floor

  Malik sees many young men with erectile issues, and they very often have pelvic floor dysfunction linked to stress and long hours of sitting, which surged during COVID. An hour of exercise doesn't offset a day of sitting, so she recommends walking more and using a standing desk.

• 05

  Pornography use is mostly a problem when it displaces real life

  The research describes 'problematic pornography use' rather than addiction, and it applies to about 4% of people in studies. Malik says porn use with healthy relationships and functioning is generally fine, and shame is itself harmful. The risk is escalating to more novel material to get the same dopamine response, and avoiding real-world intimacy. Huberman separates watching, masturbating, and masturbating to ejaculation.

• 06

  Daily low-dose tadalafil has broader uses

  Beyond the higher doses taken as needed, a daily 2.5–5 mg dose of tadalafil (Cialis) improves erectile function and is used for urinary symptoms from an enlarged prostate. Malik also uses it off-label for pelvic pain and possibly to prevent age-related fibrosis of erectile tissue, which she says isn't standard practice. L-citrulline raises nitric oxide by converting to arginine and lasts longer than arginine itself, but supplements are unregulated. Huberman warns it can trigger severe cold sores in some people.

• 07

  UTIs are common and largely preventable

  Up to 50% of women have at least one UTI. Up to a third of those have recurrent infections, meaning two or more in six months or three or more in a year. UTIs are uncommon in men because the urethra is longer, so a man's UTI should be investigated. Prevention starts with 2–3 liters of fluid, ideally water, a day.

• 08

  SSRIs often blunt sexual function

  Serotonin inhibits orgasm, which is why SSRIs are used off-label for premature ejaculation. The effect depends on dose. Options include lowering the dose if someone is doing well, switching to an antidepressant like Wellbutrin with fewer sexual side effects, or adding Cialis or Viagra.